ICC-2 Orthopedics — Disease Index & Clinical Criteria

Written by Betra Youhanna, a medical student and not a doctor — check every detail against your own teaching.

Disease Index · 95 entries across 11 categories · concept-only lectures excluded

Criteria & Scores · 19 scoring systems, classifications, and mnemonics across 10 categories

C/P — Clinical Presentation

Inves — Investigations

Mng — Management

Special — Pathognomonic / disease-unique

Bone biology & generic fracture pathology

9 entries

Osteonecrosis (avascular necrosis / AVN)

C/P

Early stage asymptomatic — usually advanced by presentation
Pain (commonest)
Clicking (loose articular fragment snapping)

Inves

X-ray normal in early disease
Crescent sign — thin radiolucent crescent below convex articular surface — earliest X-ray sign
MRI = gold standard
Bone scan if MRI unavailable

Mng

Conservative — bed rest, non-weight bearing, analgesia, treat underlying cause
Surgical — core decompression, osteotomy, replacement

Special

Sites: femoral head, distal femur, scaphoid, proximal humerus, talus, MT (Freiberg's), navicular (Kohler's), lunate (Kienbock's)
Non-traumatic: infection, sickle cell, Gaucher's (lipid storage → fat emboli), Caisson (decompression), thrombophilia, steroids, alcohol, ionising radiation
Traumatic AVN — interruption of blood supply by displaced fractures (hip, scaphoid, talus)

physiology · background · low-yield

Mechanism

Traumatic AVN also via thrombosis of intravascular capillaries in un-displaced fractures (not only vessel interruption in displaced #)

Background

Femoral-head blood supply — lateral + medial circumflex branches of profunda femoris → retinacular vessels at the base of the femoral neck (intra-capsular)

Stress fracture

C/P

Repetitive strain pain in athlete / dancer / military personnel
Steroid therapy as additional risk

Inves

— (deck silent for this section)

Mng

— (deck silent for this section)

Special

NORMAL bone subjected to repeated heavy loading — distinguishes from pathological #

Pathological fracture

C/P

Fracture with NORMAL stress
Bone weakened by structural change

Inves

Mirels' score predicts impending pathological # risk

Mng

Replace rather than fix where possible (may not unite)
Prophylactic fixation of impending # is easier and less traumatic
Mirels' >8 — consider prophylactic stabilisation

Special

Causes: osteoporosis, osteogenesis imperfecta, lytic lesion (cyst, metastasis)
Top 5 primaries that mets to bone: Lung, Thyroid, Breast, Prostate, Kidney
Mets are lytic OR sclerotic

Non-union

C/P

No healing after 2× the time normally needed

Inves

X-ray — bone-end appearance distinguishes types

Mng

Hypertrophic — STABILISATION (mechanical cause; good blood supply, flared ends + abundant callus)
Atrophic — BIOLOGICAL ENHANCEMENT (bone graft) (poor blood supply; withered ends; too-rigid fixation)
Infected non-union — debride + treat infection then fix

Special

3 types: hypertrophic / atrophic / infected
Atrophic = too-rigid fixation + poor vascularity

physiology · background · low-yield

Mechanism

Factors impairing union — diabetes, corticosteroids, NSAIDs, radiotherapy, fracture distraction, soft-tissue interposition (promoters: good blood supply, loading/micro-motion, Vit D, BMP)

Background

Union definitions — clinical: no tenderness/pain on loading; radiological: bridging bone on 3 of 4 cortices; delayed union = healing slower than expected

Mal-union

C/P

Healed bone in NON-anatomical position

Inves

X-ray

Mng

Corrective osteotomy if functionally limiting

Special

Relative problem — severity depends on location, bone, magnitude of deformity

Compartment syndrome

C/P

Pain OUT OF PROPORTION (first symptom)
Pain on PASSIVE stretch (most sensitive sign)
Tense compartment, rock-hard
Paraesthesia / hypoaesthesia (nerve ischaemia)
Absent distal pulse = LATE (amputation usually required)

Inves

Mainly CLINICAL diagnosis
Compartment pressure >40 mmHg absolute, OR delta (diastolic BP − compartment) <30 mmHg

Mng

EMERGENCY FASCIOTOMY — limb-saving
Surgical decompression of compartment
Wound left open → delayed closure / skin graft

Special

Orthopaedic EMERGENCY
Osseo-fascial pressure → reduced perfusion → irreversible muscle + neurovascular damage
Late sequel: Volkmann's ischaemic contracture (upper limb)

Fracture blisters

C/P

Skin blistering over fracture site

Inves

Clinical

Mng

Delay open fixation until blisters settle

Special

Mechanism — underlying inflammation
Prohibitive to open fixation — operating through blisters markedly increases infection risk

Fracture-related infection

C/P

Wound discharge, local sepsis signs post-fixation

Inves

Tissue / fluid culture and sensitivity

Mng

Removal of metalwork (biofilm reservoir)
Debridement + washout + antibiotics
Implants either retained OR removed and # fixed externally

Special

Causes: pre-op (open #, opportunistic), intra-op (inoculation during fixation), post-op (wound dehiscence or haematogenous spread)

Vascular injury (post-fracture)

C/P

Deformed limb, absent / weak distal pulse, prolonged CRT, cool

Inves

Doppler · CT angiography

Mng

Control external haemorrhage first
Only life-threatening injuries treated before reperfusion
Deformed pulseless limb → realign and reassess
Skeletal stabilisation (temp ex-fix) → vascular shunt or repair → delayed definitive # fixation

Special

Assumed until proven otherwise in all orthopaedic injuries

Upper limb fractures

14 entries

Clavicle fracture

C/P

2.6% of all fractures
Mechanism — fall onto affected shoulder, direct hit, or FOOSH

Inves

X-ray

Mng

Conservative — sling for 4–6 weeks, gentle ROM (counteracts arm weight and SCM pull)
Surgical — ORIF with plate & screws for: open #, neurovascular compromise, skin tenting
Lateral-end # — high non-union rate → standard ORIF

Special

Medial 1/3 protects brachial plexus, subclavian & axillary vessels, superior lung

Proximal humerus fracture

C/P

~4% of fractures
Older patient + simple fall = fragility fracture
Mostly non-displaced

Inves

X-ray

Mng

Conservative — collar & cuff (gravity holds alignment); pendulum + passive ROM at 7–10 d; active ROM at 6 wk
Young — ORIF + repair tuberosities / rotator cuff
Older — hemiarthroplasty + tuberosity / cuff repair

Special

Four osseous segments — humeral head, lesser tuberosity, greater tuberosity, humeral shaft
Adjacent nerve-injury pairing — AXILLARY nerve at risk (shared with shoulder dislocation)

Humeral shaft fracture

C/P

3–5% of fractures
Distal 1/3 spiral # — RADIAL NERVE wrist + finger drop

Inves

X-ray + careful neurovascular exam, especially radial

Mng

Conservative — U-slab OR hanging cast (gravity aligns; opposite of clavicle); 8–12 wk
Surgical — posterior plating (identify + dissect radial nerve) OR intramedullary nailing
Indications — displaced, open, NV injury, non-union

Special

Holstein-Lewis = distal 1/3 humeral spiral # with high radial-nerve injury risk
Radial nerve immobile at lateral intermuscular septum → vulnerable

physiology · background · low-yield

Background

Anatomical extent — pectoralis major insertion to the supracondylar ridge

Radial head fracture

C/P

FOOSH
Tender lateral elbow

Inves

X-ray

Mng

Non-displaced — sling 2 wk → early ROM
Displaced — plate / screws OR prosthetic replacement

Special

Radial head contributes to VALGUS stability of the elbow

Monteggia fracture-dislocation

C/P

Forearm trauma + radial head dislocation often missed

Inves

X-ray (forearm + elbow)

Mng

ALL unstable → intervention
Children — closed reduction + cast may be attempted
Adults — ORIF
Once ulna is fixed, radial head reduces

Special

Two elements — proximal 1/3 ULNA # + radial head dislocation
Easily missed (ulnar # distracting)

Galeazzi fracture

C/P

Distal forearm trauma + DRUJ dislocation
~40% complications (non-union, instability, stiffness)

Inves

X-ray (forearm + wrist)

Mng

ALWAYS surgical — radius plated, DRUJ pinned with K-wires if unstable

Special

Two elements — distal 1/3 RADIUS # + DRUJ dislocation
3× as common as Monteggia
'Fracture of necessity'

Nightstick fracture

C/P

Isolated ulnar shaft # from direct ulnar blow

Inves

X-ray

Mng

Plaster if non/minimally displaced
Plate + screws if displaced or angulated

Special

Exception to the forearm-ring rule (where shortening of one bone usually fractures or dislocates the other)

Colles' fracture

C/P

FOOSH with wrist EXTENDED
'Dinner fork' deformity
Median nerve compression risk

Inves

X-ray

Mng

Closed reduction under haematoma block + cast, OR
Closed reduction + percutaneous K-wires, OR
ORIF with plate

Special

Most common fracture in orthopaedic practice
Distal radius with DORSAL angulation, extra-articular

Smith's fracture

C/P

Fall onto FLEXED wrist
'Garden spade' deformity

Inves

X-ray

Mng

ORIF (unstable — always operative)

Special

Distal radius with VOLAR angulation, extra-articular

Barton's fracture

C/P

Wrist trauma with intra-articular component

Inves

X-ray

Mng

— (deck silent beyond categorisation; standard practice = ORIF for intra-articular #-dislocation)

Special

Fracture-dislocation of radiocarpal joint with intra-articular # of volar OR dorsal lip (volar / dorsal Barton)

Chauffeur's fracture

C/P

Wrist trauma

Inves

X-ray

Mng

— (deck silent for this section)

Special

Radial styloid fracture

Scaphoid fracture

C/P

Anatomic SNUFFBOX tenderness (dorsal)
Scaphoid TUBERCLE tenderness (volar)
Scaphoid COMPRESSION test +

Inves

X-ray — if normal but suspicion high: immobilise thumb-spica, re-image 12–21 d
CT or MRI confirms

Mng

Stable undisplaced — thumb-spica 8–12 wk
Displaced OR gap >1 mm — ORIF with HEADLESS SCREW

Special

Most common carpal-bone #
RETROGRADE blood flow (major: dorsal carpal branch of radial artery; minor: superficial palmar arch) — vascular WATERSHED
More PROXIMAL # → higher non-union risk
Total healing 10–12 wk

Boxer's fracture

C/P

Direct trauma to clenched fist
5th MCP neck pain / deformity

Inves

X-ray

Mng

Conservative — ulnar gutter splint + buddy taping in EDINBURGH POSITION (wrist 20° ext, MCP 60–70° flex, IPs ext)
Surgical — K-wiring or ORIF for open #, significant angulation, rotational deformity, intra-articular extension

Special

5th metacarpal NECK fracture

Bennett's fracture

C/P

Thumb base pain after axial load on partially flexed metacarpal

Inves

X-ray

Mng

Reduction + fixation with K-wires

Special

Most common # at base of thumb
INTRA-articular # separating palmar-ulnar aspect of 1st MC base from rest of 1st MC

Lower limb fractures

8 entries

Femoral neck fracture

C/P

Elderly with simple fall → fragility #
Young adult with NOF # → high-energy trauma (rare)

Inves

X-ray

Mng

Young — closed reduction + cannulated screws (early fixation reduces AVN / non-union risk)
Older + less active — hemiarthroplasty
Older + active and fit — total hip replacement

Special

Intracapsular — non-union prone (synovial fluid impedes healing; loss of blood supply)
Lateral ascending cervical branches of MEDIAL FEMORAL CIRCUMFLEX artery disrupted → AVN risk
1-year mortality 20–35% in geriatric NOF #
Intracapsular subtypes (high AVN risk) — femoral head, subcapital, trans-cervical
Extracapsular subtypes (blood supply preserved) — basicervical, trochanteric

physiology · background · low-yield

Background

In a child with an intracapsular NOF #, avoid replacement — attempt fixation first

Inter-trochanteric fracture

C/P

Fall in elderly; hip pain, inability to bear weight

Inves

X-ray

Mng

Stable — Dynamic Hip Screw (DHS)
Unstable — Proximal Femoral Nail (PFN)

Special

~45% of all hip fractures
LOW AVN / non-union risk (weight-bearing trabeculae + cancellous bone + good vascularity)

Sub-trochanteric fracture

C/P

Hip pain, deformity

Inves

X-ray

Mng

INTRAMEDULLARY NAIL (treatment of choice)

Special

Within 5 cm of lesser trochanter
10–30% of hip fractures
Hard to reduce intra-op due to deforming muscle forces
Risk of non-union / mal-union

Patella fracture

C/P

Inability to perform straight-leg raise
Sometimes palpable # gap
Mechanism — direct trauma OR forceful quad contraction with flexed knee

Inves

X-ray

Mng

Undisplaced + intact extensor mechanism — cylinder cast or knee immobiliser, full weight bearing
Displaced — TENSION-BAND WIRING

Special

Displacement caused by quad tendon (sup) + patellar tendon (inf) pull
Tension band converts tension forces into compression across # → promotes healing

Tibial plateau fracture

C/P

Knee pain, swelling after varus/valgus + axial load
Associated injuries — compartment syndrome, vascular injury, ligament injury, soft-tissue damage

Inves

X-ray, CT (intra-articular)

Mng

Non-displaced — hinged knee brace + NWB
Displaced — ORIF plate + screws
Severe soft-tissue compromise — temp ex-fix → delayed plate + screws

Special

INTRA-articular fracture
Patterns — lateral / medial / bicondylar

physiology · background · low-yield

Background

Intra-articular # principle — anatomical reduction with ≤2 mm articular step-off, rigid fixation, early mobilisation; complications = secondary OA + joint stiffness

Ankle fracture

C/P

Ankle pain, swelling, inability to weight-bear

Inves

X-ray

Mng

Undisplaced/stable — cast or walking boot
Displaced — ORIF
Severe swelling — temporary ex-fix until soft tissues settle

Special

Modified hinge joint — tibia, fibula, talus
Ligamentous stabilisers — deltoid (medial), lateral complex (ATFL, CFL, PTFL), syndesmosis
Patterns — isolated medial mall; isolated lateral mall; bimalleolar; trimalleolar (med + lat + posterior)
Adjacent nerve-injury pairing — HIGH FIBULAR # → COMMON PERONEAL nerve injury

Calcaneus fracture

C/P

Heel pain, swelling after fall from height
High morbidity / disability

Inves

CT — essential for extent + pre-op planning

Mng

Cast immobilisation, OR
ORIF for displaced #

Special

'Lover's fracture' — axial loading mechanism (fall from height)
Most common tarsal-bone fracture
Extra-articular ~25% — avulsion of tuberosity (Achilles), anterior process (bifurcate lig) or sustentaculum tali
Intra-articular ~75% — talus acts as hammer/wedge compressing calcaneus at subtalar joint

5th metatarsal base fracture

C/P

Lateral foot pain, swelling after inversion/sport

Inves

X-ray

Mng

Conservative — restricted weight bearing + cast or walking boot, 6–8 wk
Operative — professional athletes OR delayed healing >10 wk: ORIF with IM screw or tension-band wiring

Special

Limited blood supply → poor healing
Zone 1 — Avulsion / Dancer's / Pseudo-Jones — proximal tuberosity, peroneus brevis contraction
Zone 2 — JONES # — metaphyseal-diaphyseal junction, vascular watershed → non-union risk
Zone 3 — proximal diaphyseal, stress # in athletes

Bone & joint infection

5 entries

Acute haematogenous osteomyelitis

C/P

Malaise, fever
Tenderness over affected region
Loss of function (e.g. cannot bear weight)
Masked in elderly, immunocompromised, or after preliminary antibiotics

Inves

X-ray — only evident after ~2 wk
PET-CT = best imaging
Bone aspirate = most certain
Blood cultures if fever >38°C (bacteraemia)
CBC (leucocytosis), CRP (↑ 12–24 h), ESR (↑ 24–48 h)
MRI — caveat: some sarcomas mimic OM on MRI

Mng

Empirical antimicrobials → directed once culture back
Surgical drainage if required
Rest and splintage
Supportive — pain relief, hydration

Special

Mainly disease of children (adults if immunity compromised)
Starts at METAPHYSIS (high vascularity)
Physeal plate + separate epiphyseal blood supply contain infection in children
Organisms — S. aureus (~70%), S. pyogenes, Pseudomonas aeruginosa
Sequestrum (dead bone fragment) and involucrum (reactive new bone) are pathological hallmarks

physiology · background · low-yield

Epidemiology/Risk

Risk factors — local: trauma, chronic bone/joint disease, peripheral vascular disease, diminished sensibility, foreign bodies/implants; systemic: malnutrition, debilitating illness, diabetes, steroids, immunosuppression

Microbiology

Septic foci that seed haematogenous OM — urinary catheters, boils/abscess/septic tooth, infected needles (IVDU), sore throat, open injuries, post-surgical wounds

Mechanism

Pathological cascade — inflammation → suppuration → bone necrosis (sequestrum) → reactive new bone (involucrum) → resolution OR chronicity/sinus
Bone is a rigid compartment — pressure of acute inflammation causes vascular damage and cell death (osteonecrosis)

Subacute haematogenous osteomyelitis

C/P

Mild symptoms; patient often presents late

Inves

Imaging often shows a WELL-ENCLOSED CAVITY

Mng

Conservative if diagnosis confirmed — antibiotics + rest/splintage
Surgical if diagnosis doubtful OR conservative failed — biopsy, curette lesion, culture-directed antibiotics

Special

Lower organism virulence + more resistant host
Well-enclosed cavity on imaging = Brodie's abscess pattern

Post-traumatic osteomyelitis

C/P

Wound infection / sepsis after open # or surgery

Inves

Culture and sensitivity of tissue/fluid

Mng

Mainstay = PREVENTION (antibiotic prophylaxis per open-# guidelines)
Post-op infection — debridement + culture; implants retained or removed and # fixed externally

Special

Most common cause of osteomyelitis in ADULTS
Open # + significant soft-tissue damage = highest risk

Septic arthritis

C/P

Hot, swollen, tender joint
Inability to weight-bear (paediatrics)
Fever

Inves

CBC / TLC with differential, ESR, CRP
Aspiration — culture and sensitivity, crystals, WBC count, GRAM STAIN (fastest result)
US, MRI (imaging adds little)

Mng

Open drainage and debridement
Arthroscopic lavage
IV antibiotics per culture and sensitivity

Special

Orthopaedic EMERGENCY — pus is toxic to chondrocytes; chondrocytes do not regenerate
Kocher's NEWT criteria for paediatric SA
Organisms by age — Neonates: S. aureus, GBS, E. coli; Children: S. aureus, S. pyogenes; Adults: S. aureus + streptococci; Immunocompromised: S. aureus + mixed (E. coli, Pseudomonas)
Sequelae — resolution, spread, joint destruction

physiology · background · low-yield

Epidemiology/Risk

Risk factors — paediatric age, poor nutrition, diabetes, underlying arthritis (OA/RA), immunocompromise (HIV), IV drug abuse

Peri-prosthetic joint infection (PJI)

C/P

Redness, hotness, fever, swelling
Limitation of movement of a previously sound implant
Discharge

Inves

ESR, CRP, CBC
Joint aspiration + aspirate analysis
X-ray, radio-labelled WBC, CT, MRI

Mng

Early phase (<3 wk) — DAIR (Debridement, Antibiotics, Implant Retention)
One-stage revision — if organism KNOWN: extensive debridement + irrigation, new implant with antibiotic-loaded cement, 3 peri-op antibiotic doses
Two-stage revision — if organism unknown: stage 1 (remove implant, debride, odd-number samples 3/5/7, antibiotic-loaded cement spacer, 6 wk antibiotics) → stage 2 (remove spacer, new implant, no antibiotics)
Salvage — implant removal, arthrodesis, resection arthroplasty (Girdlestone), amputation

Special

NOT an emergency (optimise the patient first)
MSIS 2011 definite-PJI criteria
Biofilms on implant act as camouflage
3-week absolute cut-off for implant retention

physiology · background · low-yield

Other

Salvage indicated for persistent infection or sepsis/septicaemia

Hand & wrist

13 entries

Ganglion cyst

C/P

Mucous-filled cyst at wrist or tendon sheath

Inves

Clinical ± imaging

Mng

Watch and wait OR aspiration (conservative)
Excision (surgical)

Special

Sites — dorsal wrist (scapholunate, 60–70%); volar wrist (18–20%); flexor sheath (10–20%)
Causes — trauma, mucoid degeneration, synovial herniation
No true epithelial lining

De Quervain's tenosynovitis

C/P

Radial-sided wrist pain
FINKELSTEIN MANOEUVRE +ve (ulnar deviation of closed fist reproduces pain)

Inves

Clinical

Mng

Conservative — rest, steroid injection, anti-inflammatories
Surgical — release of 1st dorsal extensor compartment

Special

Stenosing tenosynovitis of the FIRST DORSAL EXTENSOR COMPARTMENT
~1:1000, F > M
Risk factors — overuse, post-traumatic, post-partum

Trigger finger

C/P

Progressive pain, clicking, catching, locking of a digit

Inves

Clinical

Mng

Steroid injection
A1 pulley release (surgical)

Special

Mechanical impingement at A1 PULLEY
Congenital form usually in the thumb; recognised in toddlers; ~30% resolve spontaneously
Acquired causes — idiopathic, traumatic, diabetes, rheumatoid

Polydactyly

C/P

Extra digit or part of a digit

Inves

Clinical

Mng

Reassurance through to surgical excision per functional disability

Special

Congenital hand anomalies overall — ~1:600 live births (polydactyly is a common subset)

Syndactyly

C/P

Fusion of ≥2 digits

Inves

Clinical

Mng

Stretching + rehabilitation through to surgical separation per disability

Special

Failure of segmentation / separation during embryo formation

Congenital trigger thumb

C/P

Locked thumb in infancy

Inves

Clinical

Mng

Stretching + rehab; surgical A1-pulley release if needed

Special

Constriction / narrowing of A1 pulley of the thumb

Dupuytren's disease

C/P

Decreased ROM affecting ADL
Painful fascial nodules
HUESTON'S TABLETOP TEST — palm flat on table; MCPJ/PIPJ contracture prevents flattening

Inves

Clinical

Mng

Surgical if rapidly progressive contracture OR inconvenience
Palmar fasciectomy — excision of diseased palmar fascia
Amputation in severe cases

Special

Benign proliferative disorder
M:F = 2:1
Digit order: ring > small > middle > index
MCPJ and/or PIPJ affected; DIPJ SPARED
Risk factors — genetic, geographical (Caucasian males), alcohol

Felon (pulp space infection)

C/P

Throbbing fingertip pain, swelling, redness

Inves

Clinical

Mng

Incision and drainage

Special

Infection within closed pulp space (fat partitioned by fibrous septae from periosteum to skin)
Raised compartment pressure → diaphyseal necrosis; epiphysis spared (blood supply enters proximal)

Pyogenic flexor tenosynovitis

C/P

Kanavel's 4 signs — flexed posture; tenderness; pain on passive extension; fusiform swelling

Inves

Clinical ± aspiration / imaging

Mng

Surgical drainage + IV antibiotics

Special

Most common organism — Staph aureus
Infection of the synovial sheath surrounding the flexor tendon

Mallet finger

C/P

Inability to actively extend DIP
Drooped fingertip

Inves

Clinical (± X-ray if avulsion)

Mng

Mallet splint

Special

Rupture or avulsion of DISTAL extensor tendon insertion

Boutonnière deformity

C/P

Flexed PIP + hyper-extended DIP
Loss of active PIP extension

Inves

Clinical

Mng

Boutonnière splint

Special

Rupture of CENTRAL SLIP of the extensor mechanism

Carpal tunnel syndrome

C/P

Numbness / tingling in radial 3½ digits
Thenar weakness or atrophy
TINEL'S sign — tap median nerve at wrist reproduces tingling
PHALEN'S test — wrist volar-flexion against gravity 60 s reproduces symptoms

Inves

Clinical ± EMG/NCS

Mng

Conservative — splint, steroid injection, medications
Surgical — release of TRANSVERSE CARPAL LIGAMENT

Special

Median nerve entrapment within carpal tunnel (9 tendons + median nerve)
Decreased canal size — OA, trauma, acromegaly
Increased contents — pregnancy, RA, alcoholism, tumour, idiopathic

Volkmann's ischaemic contracture

C/P

Claw-like hand / wrist / forearm deformity
Loss of hand function
Diminished sensation

Inves

Clinical

Mng

Mild — stretching, rehabilitation, ± tendon lengthening surgery
Moderate — tendon lengthening / transfer / bone shortening
Severe — tendon grafts; excise ischaemic muscle, fascia, tendon

Special

End-result of forearm compartment ischaemia
Causes — raised forearm compartment pressure, # complications, burns, bleeding disorders, vascular injury

Foot & ankle

7 entries

Ankle sprain

C/P

Acute — pain, swelling (per grade), inability to bear weight, ecchymosis
Chronic — recurrent sprains, popping
ANTERIOR DRAWER — ATFL
VARUS stress test — lateral ligaments
VALGUS stress test — deltoid ligament

Inves

X-ray to exclude fracture
MRI in chronic cases

Mng

Acute — RICE (Rest, Ice, Compression, Elevation)
Chronic instability — open repair or arthroscopic repair

Special

High sprain (syndesmotic) ~10–20%
Low sprain (ATFL/CFL) >90%
Mechanisms — inversion, eversion, rotation against fixed foot

Achilles rupture

C/P

Sudden snapping sound / whip
Inability to plantarflex / walk
Swelling, ecchymosis, palpable defect
SIMMONDS' (Thompson's) TEST — squeeze calf; absent plantarflexion = rupture

Inves

X-ray to exclude avulsion
MRI = gold standard

Mng

Conservative — cast in PLANTAR FLEXION (acute, medically unfit, patient preference)
Surgical — acute injury, professional athlete, open injury
Chronic ruptures — tendon lengthening OR tendon grafting

Special

Pathological rupture as a mechanism category

physiology · background · low-yield

Mechanism

Three modes of injury — traumatic (sharp injury); sports injury; pathological rupture

Achilles tendonitis & Haglund deformity

C/P

Posterior heel pain with activity
Either tendon substance or insertional

Inves

Clinical ± imaging

Mng

Conservative — supportive, activity + shoe-wear modification, physiotherapy
Surgical — open release and reinsertion

Special

HAGLUND DEFORMITY — bony prominence of posterior calcaneus near Achilles insertion → friction → tendonitis
Chronic inflammation → heterotopic calcification of tendon or retro-calcaneal bursa
Haglund Mng — excise bony prominence ± disinsertion and reattachment of Achilles tendon

Plantar fasciitis

C/P

Inferior heel pain, especially first steps
Substance or insertional

Inves

Clinical

Mng

Conservative — supportive, activity + shoe-wear modification, physiotherapy, SHOCKWAVE THERAPY
Surgical — open release

Special

Overuse / unaccustomed activity + inappropriate shoe wear

Hallux valgus

C/P

Big-toe deformity, painful bunion
Shoe-wear difficulty

Inves

X-ray to grade

Mng

Non-op (1st line) — shoe-wear modification (avoid narrow toe box), hallux valgus splint, supportive medications
Operative — variety of osteotomies; SCARF OSTEOTOMY commonly used

Special

Commonest foot deformity
F > M, narrow-toe-box shoe wear, sometimes congenital, common in RA

Hallux rigidus

C/P

Loss of motion / stiffness of 1st MTP
Tenderness over 1st MTP

Inves

X-ray — dorsal osteophytes + 1st MTP arthritis

Mng

Conservative — NSAIDs, activity modification, orthotics
Surgical — dorsal cheilectomy, 1st MTP arthrodesis, 1st MTP arthroplasty

Special

Unknown aetiology (possibly repetitive microtrauma)

Lesser-toe deformities

C/P

Toe deformity affecting footwear and gait
Forms — HAMMER toe, MALLET toe, CLAW toe

Inves

Clinical ± X-ray

Mng

— (deck silent for this section)

Special

Usually an INTRINSIC muscle pathology
May be post-traumatic (e.g. missed foot compartment syndrome)

Bone tumours

5 entries

Osteochondroma (exostosis)

C/P

Pedunculated lesion arising near the physis
May be asymptomatic; symptomatic if compressing structures

Inves

X-ray

Mng

Observation; excision if symptomatic
Excision indications for a benign bone tumour — cortical thinning >50%; mass effect on adjacent structures; benign cysts may be treated by curettage

Special

Most common BENIGN bone tumour
Cartilage cap
Usually solitary; MULTIPLE in hereditary multiple exostoses
Malignant transformation ~1%

Osteoid osteoma

C/P

Localised pain WORSE AT NIGHT
Relieved by salicylates (classic triad with night pain + localised)

Inves

CT scan (best for nidus)

Mng

Radio-frequency ablation
Burns out over years if untreated

Special

Sites — femur, tibia, spine
Grows in size but eventually 'burns out'

Osteosarcoma

C/P

Persisting bone pain, night pain, swelling, pathological fracture, paraesthesia (neural compression)
Most common around the KNEE (50%) or SHOULDER (25%)
Peak — 2nd decade

Inves

X-ray, CT, MRI, bone scan
Biopsy — image-guided; tract excised at definitive surgery (seeding risk)
Blood tests — FBC, inflammatory markers, plasma electrophoresis, U&Es, LFTs, alkaline phosphatase, PSA

Mng

Surgery + PRE-op AND POST-op chemotherapy
Amputation if vascular/neuro invasion or extensive
Reconstruction — endoprosthetic replacement or autograft (e.g. fibula for tibial tumours)

Special

Most common bone SARCOMA
Metastasises EARLY
Must be managed in tumour centre by MDT (ortho-oncology surgeon, medical + radiation oncologist, pathologist, radiologist, palliative-care, rehab, psychologist)

physiology · background · low-yield

Background

Guiding principles of primary malignant tumour treatment — must not compromise prognosis; preserve function as best as possible
Neoplasm — abnormal, excessive, inappropriate cell proliferation continuing indefinitely regardless of normal growth controls; categories benign vs malignant (primary/secondary)

Other

Most important aspect in tumour management — RECOGNITION by the treating doctor

Epidemiology/Risk

Age directs the differential — young → primary or haemopoietic; older → secondary (metastatic); trauma usually unrelated but draws attention to the lesion; red-flag systemic history — prior malignancy/radiotherapy, weight loss, lethargy

Ewing's sarcoma

C/P

Pain, swelling typically in diaphysis of a long bone
80% present in first two decades

Inves

X-ray, CT, MRI, bone scan, biopsy

Mng

Chemotherapy + LIMB-SALVAGE RESECTION ± radiotherapy

Special

Second most common malignant bone tumour
Typically DIAPHYSEAL

Metastatic bone disease (MBD)

C/P

Pain, swelling, pathological fracture
Spinal cord compression
Hypercalcaemia

Inves

X-ray, CT, MRI, bone scan
Mirels' score for impending pathological # risk

Mng

Whenever possible REPLACE rather than fix (fractures may not unite)
Prophylactic fixation for impending # (Mirels' >8)
Spinal MBD — decompression + stabilisation; follow up for fixation failure

Special

Most common BONE MALIGNANCY overall
Top 5 primaries — Lung, Thyroid, Breast, Prostate, Kidney
Lytic or sclerotic

physiology · background · low-yield

Background

Four tumour categories involving bone — benign primary; malignant primary; secondary (metastatic); haemopoietic
Rationale for prophylactic fixation of an impending # — easier and less traumatic than fixing after the fracture occurs

Spine

9 entries

Spondylosis & spinal canal stenosis

C/P

Back / neck pain, neurogenic claudication, radiculopathy / myelopathy

Inves

X-ray — degenerative changes, canal stenosis
MRI — gold standard

Mng

Step-wise (see degenerative back pain Mng)

Special

Spondylosis — disc degeneration, facet arthritis, vertebral-body osteophyte lipping, canal stenosis
Stenosis → cord compression (myelopathy) or nerve-root compression (radiculopathy)
Cervical and lumbar far more common than thoracic

Muscular back pain

C/P

Pain aggravated by activity, relieved by rest
Spasm of back muscles
Tenderness mainly PARACENTRAL (not midline)
Limited painful back ROM
May be acute exacerbation of previous chronic pain

Inves

Usually NOT necessary
X-ray may show straightening of lumbar curvature

Mng

Reassurance, activity modification, NSAIDs, muscle relaxants, back-support orthotics

Special

COMMONEST cause of back pain
Precipitants — unaccustomed activity, trauma, overuse
Causes of back pain by category — mechanical ~80% (muscular, degenerative disc, facet joint, spondylolysis/spondylolisthesis, sacroiliac joint), neurogenic ~15% (disc herniation, spinal stenosis, cervical myelopathy), non-mechanical 1–2% (infection, neoplasm, inflammatory e.g. ankylosing spondylitis), referred ~1% (aortic aneurysm, renal disease), other ~4% (somatisation, malingering)

physiology · background · low-yield

Epidemiology/Risk

Low back pain defined as pain between the costal margin and inferior gluteal folds ± leg pain; leading cause of occupational disability worldwide

Degenerative disc / facet disease & disc herniation

C/P

Back pain, radiculopathy
Cauda equina (if severe)

Inves

X-ray — narrow joint space, osteophyte lipping
MRI — gold standard if neurological deficit — disc type, canal/foramen compromise, facet state

Mng

Conservative — activity modification, NSAIDs, neurotonics (radiculopathy), physiotherapy
Injections — facet joint, epidural space, nerve root
Surgical — discectomy; decompression + instrumented fusion

Special

Causes — trauma, chronic incorrect posture, heavy lifting with faulty technique

Spondylolysis

C/P

Mechanical back pain

Inves

X-ray — OBLIQUE reveals pars morphology (absent / elongated in lytic type)
MRI — disc state, canal compromise

Mng

As for spondylolisthesis below (failed conservative 9–12 mo → fusion)

Special

Fracture or stress fracture of the PARS INTERARTICULARIS
Often precedes spondylolisthesis

Spondylolisthesis

C/P

Mechanical back pain ± radiculopathy

Inves

X-ray LATERAL — degree of slippage
X-ray OBLIQUE — pars morphology
MRI — disc state, canal compromise

Mng

Non-op — rest, limit sport, activity modification, NSAIDs, muscle relaxants, physiotherapy, injections
Operative — failed conservative 9–12 mo → instrumented or un-instrumented fusion

Special

Anterior slippage of one vertebra over another (classified by degree of slippage)
Children / adolescents — Dysplastic (congenital absence/dysplasia of pars); Lytic (microtrauma in young athletes e.g. gymnastics)
Adults — Degenerative; Post-traumatic; Pathological; Iatrogenic (injudicious posterior decompression)

Cervical myelopathy

C/P

Chronic neck pain
Brachialgia
Paraesthesia
Gait abnormalities
Bowel and bladder dysfunction
Abnormal / pathological reflexes (UMN signs)

Inves

X-ray — spondylosis, canal stenosis
MRI = gold standard — soft tissues (disc), cord changes (oedema, gliosis, MYELOMALACIA — white signal)

Mng

Non-op — analgesia, neck collar, physiotherapy including gait training
Operative — failed conservative OR progressive myelopathy → decompression + instrumentation

Special

Commonest cause — degenerative cervical spine
Mechanism — direct cord compression OR ischaemia

Cauda equina syndrome

C/P

BILATERAL sciatica
BILATERAL lower-limb weakness
Bowel and bladder INCONTINENCE
PERINEAL NUMBNESS (saddle anaesthesia)

Inves

MRI = gold standard
CT alternative

Mng

URGENT decompression — discectomy ± posterior decompression per cause

Special

Orthopaedic EMERGENCY
Cause — usually acute disc prolapse or acute compression of the cauda equina

Scoliosis

C/P

Deformity (main symptom in juveniles / adolescents)
Back pain
Rare but serious — rapid deformity progression, neurological deficit, cardiopulmonary affection

Inves

Long-spine X-ray — Cobb's angle
CT, MRI if neurological deficit
Cardiopulmonary tests if severe

Mng

Non-op (Cobb's <30°) — posture + muscle-strengthening exercises, Milwaukee brace
Operative (Cobb's >30° OR expected to progress) — surgical correction and rebalancing

Special

CORONAL plane deformity
Usually adolescent; school-screening discovery
Adult scoliosis is more symptomatic
Thoracic curves > lumbar; right deviation > left

physiology · background · low-yield

Background

Spinal deformity classification axes — onset (juvenile / adolescent / adult); morphology (hyperkyphosis / hyperlordosis / scoliosis); aetiology (congenital / acquired)

Hyperkyphosis (Scheuermann's)

C/P

Thoracic back pain
Disability rare

Inves

X-ray — assess angle
CT / MRI rarely required (only if neurological deficit)

Mng

Non-op (1st line) — muscle-strengthening + posture exercises
Operative — angle >50° → correction + spinal fixation

Special

SAGITTAL plane deformity
Postural form is commonest
Adolescent form = SCHEUERMANN'S DISEASE

Knee soft tissue

6 entries

ACL tear

C/P

Sudden knee giving way, swelling
Mechanism — landing from a jump; sudden stop with change of direction (PIVOTING); knee over-extension

Inves

Mng

ACL reconstruction (per indications — lecturer didn't detail)

Special

ACL — lateral femoral condyle → intercondylar eminence of tibia; 11 × 33 mm
Functions — restrains anterior tibial translation + internal rotation
Commonly injured ligament

physiology · background · low-yield

Exam technique

Traumatic knee history — the traumatic event; ability to walk afterwards (gauges severity); symptoms of popping, giving way, locking

PCL tear

C/P

Knee pain, swelling, instability
POSTERIOR SAG sign +ve
POSTERIOR DRAWER +ve

Inves

Mng

PCL reconstruction (per indications — lecturer didn't detail)

Special

PCL — medial femoral condyle → tibial sulcus; 13 × 38 mm
Functions — restrains posterior tibial translation + torsional forces

MCL injury

C/P

Medial knee pain after lateral-to-medial blow (VALGUS force)
Pain on valgus stress

Inves

Mng

— (deck silent for this section)

Special

MCL — medial femoral condyle → medial tibial condyle + medial tibial surface
Superficial + lateral (deep) bands
Restrains VALGUS strain at extension and 30° flexion

LCL injury

C/P

Lateral knee pain after varus force or internal-rotation force

Inves

Mng

— (deck silent for this section)

Special

LCL — lateral femoral condyle → fibula; cord-like, 3 × 66 mm
Restrains VARUS stress

Meniscal injury

C/P

Knee pain, mechanical symptoms — locking, giving way

Inves

Mng

— (deck silent for this section)

Special

Medial meniscus — C-shaped fibroelastic cartilage, type I collagen
Three functions — shock absorption, stability, force transmission

Extensor-mechanism rupture

C/P

Inability to extend knee
Mechanism — direct trauma, forceful extension, corticosteroid injection, underlying disease

Inves

Clinical ± imaging

Mng

— (deck silent for this section)

Special

Components in order — quadriceps muscles → quadriceps tendon → patella → patellar tendon → tibial tubercle
Quadriceps tendon rupture > patellar tendon rupture in frequency

Shoulder & elbow

10 entries

Subacromial impingement

C/P

Shoulder pain, painful abduction
Tenderness over AC joint
PAINFUL ARC
HAWKINS-KENNEDY test +
SCARF test +

Inves

X-ray — bony pathology
MRI = gold standard

Mng

Conservative — NSAIDs, physiotherapy, injection
Surgical — failed conservative → SUBACROMIAL DECOMPRESSION (ACROMIOPLASTY)

Special

MOST COMMON cause of shoulder pain
Causes — acromion morphology, subacromial bursitis, AC arthritis (osteophytes)

Rotator cuff tear

C/P

Shoulder pain
Inability to initiate abduction (supraspinatus tear)
JOBE'S EMPTY-CAN test — supraspinatus
Resisted external rotation — infraspinatus
GERBER'S LIFT-OFF test — subscapularis

Inves

X-ray — excludes bony pathology
MRI = gold standard

Mng

Non-op (1st line) — avoid overhead activity, physiotherapy (cuff strengthening), injection
Surgical — arthroscopic repair OR mini-open repair
ANALGESIA is the first-line non-operative measure

Special

Two patterns — chronic degenerative (chronic impingement, middle-aged/older) OR acute (older patient after fall or dislocation)
Treatment considerations — patient age and activity, mechanism (degenerative vs traumatic), tear size/depth/retraction
Continuum stage 3 — Subacromial impingement → Tendinitis → Tear → Arthropathy

physiology · background · low-yield

Background

Shoulder stabilisers — dynamic rotator cuff (supraspinatus, infraspinatus, teres minor, subscapularis) + static glenohumeral ligaments/labrum/capsule; abduction sequence — supraspinatus 0–15°, deltoid 15–90°, trapezius >90°; serratus anterior stabilises the scapula

Rotator cuff arthropathy

C/P

Shoulder pain (with activity AND at night)
Shoulder weakness, stiffness
Muscle atrophy, reduced ROM

Inves

X-ray, MRI

Mng

Non-op (1st line) — NSAIDs, physiotherapy, injection
Operative — hemiarthroplasty OR REVERSE-polarity shoulder arthroplasty

Special

END-stage of rotator cuff pathology (continuum stage 4)
Features — cuff insufficiency, glenohumeral cartilage destruction, SUPERIOR MIGRATION of humeral head, subchondral osteoporosis, humeral head collapse
TOTAL shoulder arthroplasty is CONTRAINDICATED — defective cuff support

Bicipital tendinitis

C/P

ANTERIOR shoulder pain
Other features of impingement
Tenderness over long head of biceps tendon

Inves

Mng

Non-op (1st line) — physiotherapy, NSAIDs, injection
Operative — arthroscopic TENOTOMY or arthroscopic TENODESIS

Special

Inflammatory continuum with impingement

Frozen shoulder (adhesive capsulitis)

C/P

Non-specific shoulder pain
Limitation of ACTIVE AND PASSIVE ROM
External rotation most evidently affected
Muscle wasting / surgical scars (secondary forms)

Inves

X-ray, MRI
Lab — diabetes, thyroid profile

Mng

Non-op (1st line) — physiotherapy, NSAIDs, injection
Operative — MANIPULATION UNDER ANAESTHESIA (MUA) OR arthroscopic capsular release

Special

Primary cause — ADHESIVE CAPSULITIS
Associations — diabetes, thyroid disorders
Secondary forms — post-traumatic (proximal humerus #), post-surgical (shoulder arthroscopy)

Anterior shoulder dislocation

C/P

Traumatic event with anteriorly directed force to externally rotated abducted arm
Shoulder pain, ROM loss
Arm held in external rotation
Loss of shoulder contour
PROMINENT ACROMION
EMPTY GLENOID
Must check NV status PRE and POST reduction — especially AXILLARY nerve

Inves

X-ray — confirm diagnosis + direction
CT if associated proximal humerus # (fracture-dislocation)

Mng

Non-op — acute reduction under GA → immobilisation → gradual rehab
Operative — failed closed reduction OR fracture-dislocation

Special

Most commonly dislocated joint in the body (ROM > stability)
Anterior most common; posterior commoner with electric shock / seizure (commonly missed in A&E); inferior very rare; multidirectional = global instability

Tennis elbow (lateral epicondylosis)

C/P

Pain with resisted wrist extension
Tenderness over lateral epicondyle + common extensor origin
May have decreased grip strength

Inves

MRI (usually not necessary)

Mng

Non-op (1st line) — NSAIDs, avoid provocative position, rest + ice, physiotherapy, injection, tennis-elbow clasp / brace
Operative — open or arthroscopic release of common extensor origin

Special

Overuse injury of COMMON EXTENSOR origin

physiology · background · low-yield

Background

Elbow complex — three joints: ulno-humeral (hinge), radio-capitellar (pivot), proximal radio-ulnar; greater inherent stability at the cost of limited ROM; stabilisers static (medial/lateral ligaments) + dynamic (muscles)

Golfer's elbow (medial epicondylosis)

C/P

Pain with wrist flexion and pronation
Tenderness over medial epicondyle + common flexor origin
May have decreased grip strength

Inves

MRI (usually not necessary)

Mng

Non-op (1st line) — NSAIDs, avoid provocative position, rest + ice, physiotherapy, injection, bracing
Operative — open or arthroscopic release AND reattachment of common flexor origin

Special

Overuse injury of COMMON FLEXOR-PRONATOR origin

Olecranon bursitis

C/P

Localised swelling at tip of elbow
Signs of infection / inflammation may be present (redness, hotness, tenderness, fever)
Limitation of elbow movement

Inves

X-ray (exclude bony anomaly + bursal calcification)
MRI, ultrasound
Labs to exclude gout / RA

Mng

Non-op (1st line) — rest, activity modification, elbow pads, NSAIDs, physiotherapy, injection
Operative — BURSA EXCISION

Special

Causes — elbow trauma, repeated microtrauma (students, plumbers), infection, RA, gout

Cubital tunnel syndrome

C/P

Paraesthesia of MEDIAL 1½ FINGERS
PARTIAL claw hand (less clawing than low ulnar injury — ULNAR PARADOX)
Interosseous and 1st-web-space atrophy
Intrinsic muscle weakness

Inves

X-ray (exclude bony anomaly)
EMG, NCS

Mng

Non-op (1st line) — neurotonics, night splints, NSAIDs, activity modification
Operative — OPEN RELEASE

Special

Compression neuropathy of the ULNAR nerve at the elbow
Usually between the two heads of FCU
Associated — varus/valgus elbow deformity, medial epicondylosis, burns

Joint arthritis & arthroplasty

8 entries

Osteoarthritis (generic)

C/P

Joint pain, decreased quality of life, disease progression over time

Inves

(deck silent beyond L038 scope)

Mng

Non-operative measures — weight loss; activity modification (exercise, walking aids); NSAIDs; physiotherapy; glucosamines; intra-articular injections (cortisone, viscoelastic, anaesthetic)
Operative modalities — arthroplasty (total joint arthroplasty OR hemiarthroplasty); non-arthroplasty (periarticular osteotomies, resection arthroplasty, arthrodesis, ablation)

Special

Aims of treatment — non-op: pain relief, improve QoL, delay/limit disease progression; op: pain relief + improve QoL + restore joint biomechanics + restore functional ROM
Scope of arthritis surgery — congenital (e.g. DDH); deformities around joints; post-traumatic (articular / periarticular fractures); post-septic arthritis; inflammatory (e.g. RA); degenerative (OA); endocrine (e.g. gout); haematological (haemophilia, sickle cell); tumours

Hip arthroplasty — THR vs hemiarthroplasty

C/P

Advanced hip arthritis (femoral and/or acetabular)

Inves

(deck silent beyond L038 scope)

Mng

Total hip arthroplasty (THR) — replace BOTH femoral AND acetabular components
Hemiarthroplasty — replace ONLY the femoral component

Special

THR indications — young patients (<60); old patients with active lifestyle; advanced hip arthritis (femoral AND acetabular)
Hemiarthroplasty indications — old patients with limited daily activities; old patients with neuromuscular disorders (e.g. Parkinsonism); old patients with cognitive impairment (e.g. dementia)

Total knee arthroplasty (TKA)

C/P

End-stage knee arthritis

Inves

(deck silent beyond L038 scope)

Mng

Operative steps — exposure → tibial preparation → femoral preparation → component insertion

Special

Arthroplasty concepts (all joints) — remove diseased cartilage; prepare bony surfaces; cemented OR cementless implants
Bearing materials — metal-on-polyethylene; metal-on-metal; ceramic-on-polyethylene; ceramic-on-ceramic
Other joints that can be replaced — shoulder, fingers/toes, elbow, ankle, intervertebral disc
Complications of arthroplasty — peri-prosthetic joint infection (PJI), dislocation, limb-length discrepancy, osteolysis, wear and tear of the polyethylene component

High tibial osteotomy (HTO)

C/P

Young patient with varus/valgus knee deformity and early OA

Inves

(deck silent beyond L038 scope)

Mng

Periarticular osteotomy of proximal tibia to restore normal joint axis

Special

Indications — young patients (<60); BMI <30; varus AND valgus deformities
Aim — restore normal joint axis; hinder OA progression

Periacetabular osteotomy (PAO)

C/P

Shallow acetabulum (hip dysplasia spectrum)

Inves

(deck silent beyond L038 scope)

Mng

Periarticular osteotomy around the acetabulum to reorient it

Special

Indications — shallow acetabulum
Aim — improve femoral head coverage; hinder OA progression

Resection arthroplasty

C/P

Salvage indication (e.g. failed hip arthroplasty; painful CMC arthritis)

Inves

(deck silent beyond L038 scope)

Mng

Excise the diseased joint surfaces WITHOUT prosthetic replacement

Special

Examples — GIRDLESTONE procedure (hip); TRAPEZIECTOMY (thumb CMC)

physiology · background · low-yield

Mechanism

Excision (resection) arthroplasty — excise enough bone from the articulating parts to create a gap; fibrous tissue forms in the gap giving a pseudo-joint where movement can occur (e.g. trapeziectomy)

Arthrodesis

C/P

End-stage joint disease where arthroplasty is contraindicated or not preferred

Inves

(deck silent beyond L038 scope)

Mng

Abolish the joint by TRANSFIXING bony ends
Joint fixed in FUNCTIONAL position
May be converted to arthroplasty LATER on

Special

One of the four non-arthroplasty surgical options (periarticular osteotomies, resection arthroplasty, arthrodesis, ablation)
Treatment of choice for a painful or unstable joint where STIFFNESS does not seriously affect function
Classical arthrodesis sites — spine, tarsus, ankle, wrist, thumb MCP joint, interphalangeal joints

Joint ablation (denervation)

C/P

Chronic joint pain not amenable to other modalities

Inves

(deck silent beyond L038 scope)

Mng

Joint DENERVATION — ablate / cut ARTICULAR branches of sensory nerves

Special

Risk of developing CHARCOT joint (loss of protective sensation)

Additions — Approach & OSCE

1 entries

Open fracture (compound fracture)

C/P

Fracture with direct communication to the external environment (older name: compound fracture)
Low-energy vs high-energy injury
IN-out mechanism (bone pokes out) usually cleaner; OUT-in (object pokes in) more contaminated

Inves

Open-fracture history — wound size, blood loss, tetanus status, level of consciousness, other (often-missed) injuries
Graded by the Gustilo classification (see Criteria tab)

Mng

Initial — irrigate with 1-2 L saline, remove gross contamination, photograph wound, saline-soaked dressing, backslab, broad-spectrum antibiotics, tetanus prophylaxis
All open # assumed contaminated — urgent debridement (within 24 h), wash 5-6 L saline, repeat debridements until clean
Primary debridement — trim skin edges, remove foreign material, excise non-viable tissue, leave open if necessary
Temporary stabilisation if needed → definitive fixation + soft-tissue cover

Special

Surgical motto — 'Dilution is the solution to pollution'
Historical pre-WWI treatment was amputation — 75% mortality
Gustilo IIIB = extensive periosteal stripping (needs plastic cover); IIIC = vascular injury needing repair; farm injuries automatically ≥IIIA

Foundational frameworks

6 entries

Four R's of fracture management

Order

1. Resuscitation
2. Reduction
3. Immobilisation
4. Rehabilitation

ATLS primary survey — ABCDE

Sequence

A — Airway maintenance with cervical-spine restriction
B — Breathing and ventilation
C — Circulation with haemorrhage control
D — Disability
E — Exposure / environmental control

AMPLE history mnemonic

Use — emergency / multiply-injured patient.

A — Allergies
M — Medications
P — Past medical history
L — Last meal
E — Events surrounding injury

Apley's examination framework

Use — system for clinical examination popularised by Alan Apley.

Look — proper exposure; shape, posture, deformity; skin (scars, swelling, trophic changes); general appearance
Feel — skin temperature; soft tissues; bone/joint outlines; tenderness
Move — active + passive ROM
Special tests — disease-specific (e.g. anterior drawer for ACL); neurological exam; vascular state; joint above AND joint below

RICE — acute soft-tissue / ankle sprain

R — Rest
I — Ice
C — Compression
E — Elevation

Edinburgh position (Boxer's / 5th MC neck #)

Wrist extended 20°
MCP flexed 60–70°
IPs in extension

Open-fracture classification

1 entries

Gustilo classification (open fractures)

Type	Wound	Tissue / energy	Coverage
I	≤1 cm	Minimal contamination	—
II	1–10 cm	Moderate soft-tissue injury	—
IIIA	usually >10 cm	High energy, extensive soft-tissue damage, contaminated	ADEQUATE tissue for flap coverage
IIIB	—	Extensive PERIOSTEAL stripping	Requires soft-tissue coverage (plastic surgeon)
IIIC	—	Associated vascular injury	Vascular repair required regardless of soft-tissue grade (vascular surgeon)

Rule — Farm injuries are automatically AT LEAST IIIA.

Pathological-fracture risk

1 entries

Mirels' score (MBD impending fracture)

Use — predicts whether a metastatic bone lesion is at risk of pathological fracture.

Threshold — score >8 → consider PROPHYLACTIC stabilisation.

Deck reference only — lecturer did not detail the four components individually.

Compartment syndrome

1 entries

Compartment-pressure thresholds

Absolute compartment pressure >40 mmHg
OR delta (diastolic BP − compartment pressure) <30 mmHg
Diagnosis is mainly CLINICAL — pressure measurements support

Septic arthritis & PJI

4 entries

Kocher's criteria — NEWT (paediatric septic arthritis)

N — Non-weight-bearing
E — Elevated ESR
W — White-cell count elevated
T — Temperature (fever)

MSIS 2011 definition of definite PJI

Either major criterion

Sinus tract communicating with the prosthesis, OR
Pathogen isolated by culture from ≥2 separate tissue / fluid samples from the affected prosthetic joint

OR 4 of 6 minor criteria

Elevated serum ESR AND CRP
Elevated synovial leukocyte count
Elevated synovial neutrophil percentage (PMN%)
Presence of purulence in the affected joint
Isolation of a microorganism in ONE culture of periprosthetic tissue or fluid
>5 neutrophils / HPF in 5 HPFs on histology at ×400

DAIR (early-phase PJI, <3 weeks)

D — Debridement
A — Antibiotics
I — Implant Retention

Absolute cut-off — 3 weeks from symptom onset.

One- vs two-stage PJI revision

Stage	One-stage	Two-stage stage 1	Two-stage stage 2
Organism status	KNOWN (cultured on aspiration)	UNKNOWN	—
Steps	Extensive debridement + irrigation; new implant with antibiotic-loaded cement	Remove implant; extensive debridement; odd-number samples (3, 5, 7); antibiotic-loaded cement spacer	Remove spacer; new implant
Antibiotics	3 peri-op doses only	6 weeks post-op	None

Foot zones

1 entries

5th metatarsal base zone classification

Zone	Name	Location	Mechanism / risk
1	Avulsion / Dancer's / Pseudo-Jones	Proximal tuberosity	Peroneus brevis contraction
2	JONES #	Metaphyseal–diaphyseal junction	Vascular WATERSHED → non-union risk
3	—	Proximal diaphyseal, distal to 4th–5th MT articulation	Stress fracture in athletes

Spinal deformity thresholds

2 entries

Cobb's angle — scoliosis thresholds

Long-spine X-ray determines angle
<30° — non-op (posture, muscle strengthening, Milwaukee brace)
>30° OR expected to progress — operative correction + rebalancing

Hyperkyphosis angle threshold

>50° — operative correction + spinal fixation

Synovial fluid

1 entries

Synovial fluid — pattern table

Condition	Appearance	Viscosity	WBC	Crystals	Biochem / bact
Normal	Clear yellow	High	Few	—	As plasma
Septic arthritis	Purulent	LOW	+ (TLC >10,000/mm³)	—	LOW glucose; +ve bacteriology
Gout	Cloudy	Normal	++	URATE	—
Pseudogout	Cloudy	Normal	+	PYROPHOSPHATE	—

Provocative tests reference

1 entries

Provocative tests — shoulder, hand, ankle, knee, Achilles

Hawkins-Kennedy — subacromial impingement
Scarf test — AC joint pathology / impingement
Painful arc — subacromial impingement
Jobe's empty-can — supraspinatus
Resisted external rotation — infraspinatus
Gerber's lift-off — subscapularis
Tinel's — median nerve (carpal tunnel)
Phalen's — 60 s wrist volar-flexion against gravity reproduces CTS symptoms
Finkelstein — De Quervain's (ulnar deviation of closed fist)
Hueston's tabletop — Dupuytren's
Anterior drawer (ankle) — ATFL
Varus stress (ankle) — lateral ligaments
Valgus stress (ankle) — deltoid ligament
Posterior sag, posterior drawer (knee) — PCL
Simmonds' (Thompson's) test — Achilles rupture (squeeze calf, no plantarflexion = rupture)

Arthroplasty complications

1 entries

Complications of arthroplasty

Five complications (L038 s16)

Peri-prosthetic joint infection (PJI)
Dislocation
Limb-length discrepancy (LLD)
Osteolysis
Wear and tear of the polyethylene component

MSK Imaging — Fracture Description & Shoulder Instability

Fracture description schema

Regions: physis (growth plate) · epiphysis · metaphysis · diaphysis
Complete vs incomplete — children: bowing/plastic, torus/buckle, greenstick; complete: simple, comminuted
Shape by line: transverse · oblique · spiral · longitudinal
Alignment: displacement · angulation (medial = valgus, lateral = varus) · rotation · overriding + foreshortening (bayonet apposition) · distraction

Shoulder instability & impingement

Anterior dislocation → Hill-Sachs (postero-lateral humeral head impaction) + Bankart (I cartilaginous: antero-inferior labrum/IGHL avulsion + periosteum; II bony: + antero-inferior glenoid rim fracture)
Posterior dislocation → reversed Hill-Sachs (antero-medial impaction) + reversed Bankart
Impingement: supraspinatus partial tear (downsloping acromion, AC OA) → complete tear + retraction

MSK Imaging — Spine (Modic, Spondylolisthesis, Disc Levels)

Modic end-plate marrow (T1 / T2)

Type I oedema — low T1, bright T2
Type II fatty — bright T1 and T2
Type III sclerotic — low T1 and T2

Spondylolisthesis

Scottie dog (oblique X-ray): collar = pars interarticularis defect = spondylolysis
Lytic (pars break → only body slips → WIDE canal) vs degenerative (bilateral facet arthropathy, intact arch → NARROW canal)
Graded I–V by % vertebral slippage (Meyerding: I <25%, II 25–50%, III 50–75%, IV 75–100%, V >100% spondyloptosis)

Cervical / lumbar disc → root

C4/5→C5 (deltoid+biceps, biceps reflex) · C5/6→C6 (biceps+wrist ext, brachioradialis) · C6/7→C7 (triceps+wrist flex, triceps) · C7/T1→C8 (hand intrinsics, no reflex)
L3/4→L4 (tibialis anterior, patellar reflex) · L4/5→L5 (EHL, no reflex) · L5/S1→S1 (fibularis longus/brevis, Achilles reflex)

MSK Imaging — Joint MRI & Bone Lesions

Knee

Meniscal signal grades: 1 globular (asymptomatic) · 2 linear not reaching surface · 3 reaches one articular surface (tear) · 4 complex, both surfaces
Bucket-handle = double PCL + double anterior horn sign; discoid = lateral, bow-tie on >3 sagittal cuts
Ligament sprain vs tear = fibre continuity (ACL, PCL, MCL, LCL); chondromalacia patellae grades 0–IV; OCD (male 10–20 y, medial femoral condyle)

Sacroiliitis MRI phases

Oedema (STIR bright, active, most sensitive) → fatty (bright T1/T2, STIR-suppressed, chronic) → sclerotic (low T1/T2, visible on plain X-ray)

AVN, infection & tumour

Perthes (femoral-head AVN in children) · Kienböck (lunate AVN) · scaphoid proximal-pole AVN
Osteosarcoma sunburst periosteal reaction · chronic osteomyelitis = sequestrum + cloaca + involucrum
Ankle: inversion → ATF ligament; eversion → deltoid tear + medial malleolus contusion; Achilles rupture vs tendonitis = fibre continuity

Fracture fixation principles

1 entries

Fracture fixation — implant choice (screw · nail · plate)

Step 1 — operate or not?

Default is CONSERVATIVE (cast / splint / sling) for a stable, extra-articular, undisplaced fracture
OPERATE if ANY — displaced / unstable · intra-articular (needs anatomical reduction) · open · neurovascular injury · non-union prone · failed conservative · patient/function demand (e.g. athlete)

Step 2 — pick the implant by the problem it solves

Implant	Use it when…	Why (mechanics)	Deck examples
Cast / splint / sling	stable, extra-articular	just needs holding while it heals	Colles' (closed reduction + cast), stable scaphoid (thumb spica), Boxer's (ulnar gutter), stable ankle
K-wires	small bone, unstable, too small to plate	pin fragments in position	Bennett's, Colles' (percutaneous option), DRUJ in Galeazzi, paediatric
Plate & screws (ORIF)	forearm shaft OR intra-articular	gives ANATOMICAL reduction (≤2 mm step-off)	Smith's, Barton's, radial head, tibial plateau, displaced ankle, Galeazzi radius, adult Monteggia
Screw (cannulated / headless)	juxta-articular or small bone	COMPRESSES across a single fracture line	femoral neck young (cannulated), scaphoid displaced (headless)
Intramedullary (IM) nail	long-bone SHAFT	load-sharing rod down the canal → early weight-bear	sub-trochanteric, humeral shaft, 5th MT (IM screw)
Tension-band wiring	a tendon is pulling the fragments apart	converts tension into compression across the #	patella
Replacement / arthroplasty	fragment can't heal / blood supply dead	replace rather than fix	femoral neck (old), comminuted proximal humerus (old), shattered radial head
Temporary external fixation	soft tissues too swollen / contaminated to operate now	stabilise now, definitive fixation later	tibial plateau + swelling, ankle + swelling, vascular injury

Screw vs nail — the core rule

Near a joint / small bone → SCREW — compresses two fragments together across one line
Mid-shaft of a long bone → NAIL — a rod down the canal splints the whole shaft and shares load

Hip fracture rule (intracapsular vs extracapsular)

Femoral neck = intracapsular → blood supply (medial femoral circumflex) at risk → AVN-prone → young: urgent cannulated screws; old low-demand: hemiarthroplasty; old active: THR (REPLACE)
Trochanteric = extracapsular → supply preserved, low AVN → FIX it: stable inter-trochanteric = DHS; unstable = PFN; sub-trochanteric = IM nail
One line — intracapsular = replace, extracapsular = fix